Healthcare Provider Details

I. General information

NPI: 1083725147
Provider Name (Legal Business Name): DAVID C. ANDERHOLM, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7115 FORTHUN RD SUITE 105
BAXTER MN
56425-8597
US

IV. Provider business mailing address

7115 FORTHUN RD SUITE 105
BAXTER MN
56425-8597
US

V. Phone/Fax

Practice location:
  • Phone: 218-454-0090
  • Fax: 218-454-0091
Mailing address:
  • Phone: 218-454-0090
  • Fax: 218-454-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLIOT RICHELSON
Title or Position: DIRECTOR, PRESIDENT, SECRETARY, AND
Credential: M.D.
Phone: 904-605-4986